Provider Demographics
NPI:1306069299
Name:SHOUN, ROBERT LAFORREST (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LAFORREST
Last Name:SHOUN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2474
Mailing Address - Country:US
Mailing Address - Phone:803-348-8976
Mailing Address - Fax:
Practice Address - Street 1:125 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3655
Practice Address - Country:US
Practice Address - Phone:803-348-8976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3801Medicaid